Sunday, April 24, 2016

No other part of the battlefield represented such an odd mixture of hope and terror as the field hospital. The writings of veterans almost universally picture it as a place to be feared and avoided if at all possible. To the men who survived the conflict, hospitals presented a gruesome compendium of the horrors of the war, second only to the sight of torn, bloated, lifeless bodies on the field of battle. Yet the field hospital's staff, medicines, facilities, and surgeons were the only hope desperately wounded men had to save life and limb.

It was predictable that there would be contradictory views of the hospital. Only there could wounded soldiers find relief from their pain, comfort and assistance in their weakened and helpless condition, and life-saving surgery and medical care. At the same time, however, the hospital was a site of agony and misery—the place where men with mangled limbs, bleeding bodies, torn flesh, blinded eyes, and worse, were brought together. It was the spot where overworked doctors hurriedly examined and probed painful wounds; where, all too often, surgeons used their instruments to amputate shattered and infected limbs. Field hospitals were facilities where mortally wounded men were given a few comforts and set aside to die. They were in short a concentration of the vilest aftereffects of battle.

The common perception of Civil War hospitals and surgeons was generally quite negative during the conflict. Time did little to alter that point of view and, in fact, did much to reinforce it. The disorganized and grossly inadequate efforts made by both Union and Confederate medical departments at the start of the war were widely reported in newspapers of the day. However, both sides were able to rapidly improve the standard of care delivered to sick and wounded soldiers alike. This remarkable advance in battlefield medical practices saved many lives before the war was over (Bollet 2002, p. xiii).

Hospital Trains

The Civil War was the first railroad war. Both sides used trains to move troops and supplies to the front and transport sick and wounded men to general hospitals located throughout the North and South. Initially, ordinary boxcars were used to haul patients. These cars had no provisions for the feeding, care, or comfort of wounded soldiers, who endured journeys lasting hours, and sometimes days, without medical attention or basic necessities. The agony and misery such trips entailed was extreme, provoking demands for change.

The industry-poor Confederacy could do little to remedy such problems. The North, with facilities for building locomotives and railway cars, developed hospital trains. Specially designed "ambulance cars" were built, each containing space for thirty hospital litters, suspended three high from stanchions by rubber straps. The litters, complete with mattresses and pillows, swung gently, preventing the pain previously caused by any movement of the trains. Each car had a seating area and a fully stocked pantry. A stove heated the cabin. Kitchen and dining cars accompanied the ambulance cars, as did sleeping cars for doctors and nurses staffing the train. The locomotive and tender were painted bright red, and U.S. Hospital Train was emblazoned in large red letters on every car. These trains provided all the facilities of an efficient and well-regulated hospital. Sick and injured troops were never without food, water, comfort, or medical care while being carried to their destination.

But improvements and innovations seldom made headlines and largely went unnoticed. The horror, fear, and sadness surrounding even an efficiently run and effective field hospital kept most veterans from seeing or understanding the vast change for the better made by dedicated doctors, surgeons, officers, and administrators. Postwar memoirs and regimental histories are full of stories of needless amputations conducted without anesthesia. Also prevalent are tales of incompetent surgeons, indifferent doctors, callous nurses or stretcher-bearers, and half-trained medical students conducting unnecessary surgery on injured soldiers simply to gain experience (Bollet 2002, p. xiii).

Perception vs. Reality

The attitude of many soldiers toward the men who worked in field hospitals, and toward what went on in them, is abundantly clear in an account given by a Union officer wounded during the May 23 to July 9, 1863, siege of Port Hudson, Louisiana:

The surgeons used a large Cotton Press for the butchering room & when I was carried into the building and looked around I could not help comparing the surgeons to fiends…. [A]ll around on the ground lay wounded men; some of them shrieking, some cursing & swearing & some praying; in the middle of the room was some 10 or 12 tables just large enough to lay a man on; these were used as dissecting tables & they were covered with blood; near & around the tables stood the surgeons with blood all over them & by the side of the tables was a heap of feet, legs & arms. (Wiley 1952, p. 148)

The bloody mass of waiting wounded, the tables, the appearance of the surgeons, and the agony of the injured were, of course, very real. But the words this injured soldier used to describe what he saw—"butchering," "fiends," "dissecting"—reveal all too well how he perceived those who were about to save his life. His point of view was hardly unusual. For people unaccustomed to the sight of mass casualties gathered together, or the instruments and operations of surgeons, revulsion and horror were common reactions. Wounds, after all, are horrific to look at; suffering is difficult to hear or see, and the methods used by doctors and surgeons to treat major wounds must, of necessity, sometimes cause pain. The very tools used to repair and heal—probes, saws, scalpels, needles—were enough to make most witnesses shudder, especially if they did not fully understand what was being done or why. Any modern person who has felt ill at ease while staring at medical instruments in a doctor or dentist's office has had a similar, although certainly less intense, experience.

Furthermore, field hospitals posed dangers that were unrecognized at the time. The Civil War was fought just prior to the discovery of bacteria and their role in causing infections, and the development of methods of sterilization used to prevent the transmission of disease from cross-contamination.

One Federal surgeon, looking back on the war from the vantage point of 1918, was amazed at the ignorant practices employed between 1861 and 1865:

We operated in old blood-stained and often pus-stained coats…. We used un-disinfected instruments from un-disinfected plush-lined cases, and still worse, used marine sponges which had been used in prior pus cases and had been only washed in tap water. If a sponge or an instrument fell on the floor it was washed and squeezed in a basin of tap water and used as if it were clean. Our silk to tie blood vessels was un-disinfected…The silk with which we sewed up all woulds was undisinfected. If there was any difficulty threading the needle we moistened it with…bacteria-laden saliva, and rolled it between bacteria-infected fingers. We dressed wounds with clean but undisinfected sheets, shirts, tablecloths, or other old soft linen rescued from the family ragbag. We had no sterilized gauze dressing, no gauze sponges…. We knew nothing about antiseptics and therefore used none. (Wiley 1952, p. 148)

Little wonder then, that wounds frequently became infected even after successful operations. Very often, injured men who survived the trip from the battlefield to the field hospital and underwent life-saving procedures died weeks or months later from the unrecognized bacteria that caused gangrene, tetanus, and other complications.

Nonetheless, field hospitals saved many more lives than they took. Fortunate to be working, for the most part, on healthy young men, inured to hardship by a soldier's life, surgeons and doctors ministered to a population with a better than average likelihood of healing and recovering. If infection could be avoided, and the wound was at all survivable, medical personnel usually managed to save life, if not limb.

Supplies

At the war's outset, the typical surgeon used his own personal instruments, usually brought into service from prewar private practice. He was authorized by the government to purchase and use whatever medicines or supplies he thought appropriate. Hospital stewards in every regiment carried a medical knapsack, which was similar in shape and size to the pack carried by infantrymen and worn in identical fashion. Union hospital steward Charles Johnson recalled that this knapsack contained such emergency supplies as "bandages, adhesive plaster, needles, artery forceps, scalpels, spirits of ammonia, brandy, chloroform and ether" (Commager 1973 [1950], pp. 195–196).

The type and quantity of supplies and medicines at the field hospital was constrained by the necessity of mobility. The number of wagons and ambulances assigned to a hospital was finite, and care had to be taken not to overload vehicles that would be pulled by mules or horses over rough and difficult roads. The standard stock of medicines in a field hospital consisted of "opium, morphine, Dover's powder, quinine, rhubarb, Rochelle salts, castor oil, sugar of lead, tannin, sulphate of copper, sulphate of zinc, camphor, tincture of opium, tincture of iron, tincture opii, camphorate, syrup of squills, simple syrup" and a wide variety of alcohol (Commager 1973 [1950], p. 195). Most medicines were compounded in liquid or powdered form. Few pills were available, so powders were typically mixed with water and drunk by the patient. Precise measurements were not made and surgeons simply apportioned the amount of medicine they thought necessary (Commager 1973 [1950], p. 195).

The resulting lack of uniformity in supplies, instruments, and medicines proved a logistical nightmare. Combined with the widely varying levels of experience and skill found among surgeons and stewards, it also frequently resulted in poor or indifferent care for the sick and wounded. By late 1862, however, changes born of experience and good leadership began to address these concerns.

Among the many vital improvements made by Jonathan Letterman, medical director of the Army of the Potomac from July 1862 to January 1864, was standardization of equipment and medicines for field hospitals. …